Electronic cigarettes sounded like a good idea when they were developed in the early 2000s. Designed to heat and vaporize a solution of nicotine dissolved in propylene glycol or glycerol, electronic cigarettes promised two benefits. First, people addicted to nicotine could continue using the drug without also breathing in the tar and ashes associated with burning tobacco. And second, there was the hope that e-cigarettes might become a tool for smoking cessation. It was not anticipated that e-cigarettes would initiate new populations into nicotine addiction, and ultimately into tobacco and marijuana use.
A new study now documents and measures the increased risk of tobacco and marijuana use associated with e-cigarette use among youth.[i] Researchers followed adolescents (12-17) and young adults (18-25) over eight years (2013-2021) to examine the association between e-cigarette use and later substance initiation. Adolescents using e-cigarettes were over 21 times more likely to start smoking tobacco cigarettes than those who never used e-cigarettes, and nearly seven times more likely to initiate marijuana use. When non-cigarette tobacco products were combined with e-cigarettes, adolescents became over 53 times more likely to start smoking tobacco cigarettes. Young adult e-cigarette users were found to have an 11 times greater likelihood of starting tobacco cigarette use and were six times more likely to start using marijuana. The association of tobacco and cannabis use with e-cigarette use led researchers to support efforts to prevent e-cigarette initiation among adolescents and young adults.
Three factors likely impacted the association documented in this study. First, legal recreational cannabis, including electronic devices delivering high-concentration THC vapor, became increasingly available after 2016. Second, during the COVID pandemic, most psychoactive substances had an uptick in use. And perhaps most importantly, Juul greatly popularized nicotine vaping among the young population being studied.
Juul spun off from its parent company in 2017 and quickly increased its market share of e-cigarette sales to 73 percent by 2018. Juul achieved this remarkable growth through aggressive social media marketing, including advertising in magazines (Seventeen), on television (Nick Jr. Channel), and on gaming sites, all obviously intentionally targeting youth. After agreeing with government regulators to restrict flavors targeting youth (eighth graders favored mango while mint was favored by 10thand 12th graders), Juul’s market share fell to 42 percent in 2020, and after agreeing to end marketing to youth, its share fell to 28 percent in 2022.
There is good reason to be skeptical about data based on mere association as opposed to a clear cause-and-effect relationship. For example, nearly 100 percent of people arrested for driving while intoxicated in the U.S. have eaten French fries at McDonald’s, but this association did not cause, or even contribute to, their being arrested for a DUI. While such associations are frivolous and without meaning, others can have useful predictive value. For example, a recent study found an association between poor sleep patterns during childhood and later use of alcohol and marijuana.[ii] This association could be an early marker of dysregulation that later contributes to substance initiation and continued use. While disruptive sleep in children can be seen as a risk factor for substance use, good luck trying to get your child to sleep more!
Finally, there are associations such as the use of e-cigarettes that both highly likely contribute to later tobacco and cannabis use and provide realistic preventative actions. Parental controls, youth education, and government policy can all mitigate early e-cigarette use. Will a decrease in early e-cigarette use lead to delayed or decreased tobacco and cannabis use? While common sense tends to support this expectation, only additional research holds the answer. Meanwhile, successfully reducing early e-cigarette use is good in and of itself, as the consequences of vaping high concentrations of nicotine early in life are currently unknown.